Framework and Schema are False Synonyms: Defining Terms to Improve Learning.

Clinical reasoning is an essential expertise of health care professionals that includes the complex cognitive processes that lead to diagnosis and management decisions. In order to optimally teach, learn, and assess clinical reasoning, it is imperative for teachers and learners to have a shared understanding of the language. Currently, educators use the terms schema and framework interchangeably but they are distinct concepts. In this paper, we offer definitions for schema and framework and use the high-stakes field of aviation to demonstrate the interplay of these concepts. We offer examples of framework and schema in the medical education field and discuss how a clear understanding of these concepts allows for greater intentionality when teaching and assessing clinical reasoning.

Advancing the assessment of clinical reasoning across the health professions: Definitional and methodologic recommendations.

The importance of clinical reasoning in patient care is well-recognized across all health professions. Validity evidence supporting high quality clinical reasoning assessment is essential to ensure health professional schools are graduating learners competent in this domain. However, through the course of a large scoping review, we encountered inconsistent terminology for clinical reasoning and inconsistent reporting of methodology, reflecting a somewhat fractured body of literature on clinical reasoning assessment. These inconsistencies impeded our ability to synthesize across studies and appropriately compare assessment tools. More specifically, we encountered: 1) a wide array of clinical reasoning-like terms that were rarely defined or informed by a conceptual framework, 2) limited details of assessment methodology, and 3) inconsistent reporting of the steps taken to establish validity evidence for clinical reasoning assessments. Consolidating our experience in conducting this review, we provide recommendations on key definitional and methodologic elements to better support the development, description, study, and reporting of clinical reasoning assessments.

Psychometric validation of the reconstructed version of the assessment of reasoning tool.

BACKGROUND: Assessing learners' competence in diagnostic reasoning is challenging and unstandardized in medical education. We developed a theory-informed, behaviorally anchored rubric, the Assessment of Reasoning Tool (ART), with content and response process validity. This study gathered evidence to support the internal structure and the interpretation of measurements derived from this tool. METHODS: We derived a reconstructed version of ART (ART-R) as a 15-item, 5-point Likert scale using the ART domains and descriptors. A psychometric evaluation was performed. We created 18 video variations of learner oral presentations, portraying different performance levels of the ART-R. RESULTS: 152 faculty viewed two videos and rated the learner globally and then using the ART-R. The confirmatory factor analysis showed a favorable comparative fit index = 0.99, root mean square error of approximation = 0.097, and standardized root mean square residual = 0.026. The five domains, hypothesis-directed information gathering, problem representation, prioritized differential diagnosis, diagnostic evaluation, and awareness of cognitive tendencies/emotional factors, had high internal consistency. The total score for each domain had a positive association with the global assessment of diagnostic reasoning. CONCLUSIONS: Our findings provide validity evidence for the ART-R as an assessment tool with five theoretical domains, internal consistency, and association with global assessment.

Teamwork in clinical reasoning - cooperative or parallel play?

Teamwork is fundamental for high-quality clinical reasoning and diagnosis, and many different individuals are involved in the diagnostic process. However, there are substantial gaps in how these individuals work as members of teams and, often, work is done in parallel, rather than in an integrated, collaborative fashion. In order to understand how individuals work together to create knowledge in the clinical context, it is important to consider social cognitive theories, including situated cognition and distributed cognition. In this article, the authors describe existing gaps and then describe these theories as well as common structures of teams in health care and then provide ideas for future study and improvement.

The Management Script: A Practical Tool for Teaching Management Reasoning.

Management reasoning, a component of clinical reasoning, has become an important area for medical education research given its inherent complexity, role in medical decision making, and association with high-value care. Teaching management reasoning requires characterizing its core concepts and identifying strategies to teach them. In this Perspective, the authors propose the term "management script" to describe the mental schema that clinicians develop and use in medical decision making. Management scripts are high-level, precompiled, conceptual knowledge structures of the courses of action that a clinician may undertake to address a patient's health care problem(s). Like illness scripts, management scripts have foundational elements that are shared by most clinicians but are ultimately idiosyncratic based on each clinician's unique history of learning and experience. Applying management scripts includes 2 steps-(1) management script activation and (2) management option selection-which can occur reflexively (unconsciously) or deliberately (consciously), similar to, respectively, the System 1 thinking and System 2 thinking of dual process theory. Management scripts can be taught for different conditions by using management script templates, educational scaffolds that provide possible courses of action to address a health care problem at any stage. Just as learners use system-based or organ-based frameworks to generate a differential diagnosis, students can use a generic management script template early in training to develop management scripts for specific problems. Future research directions include exploring the role of management scripts in medical education and quality improvement practices.

Clinical Reasoning as a Core Competency.

Diagnostic error is a challenging problem; addressing it effectively will require innovation across multiple domains of health care, including medical education. Diagnostic errors often relate to problems with clinical reasoning, which involves the cognitive and relational steps up to and including establishing a diagnostic and therapeutic plan with a patient. However, despite a call from the National Academies of Sciences for medical educators to improve the teaching and assessment of clinical reasoning, the creation of explicit, theory-informed clinical reasoning curricula, faculty development resources, and assessment tools has proceeded slowly in both undergraduate and graduate medical education. To accelerate the development of this critical element of health professions education and to promote needed research and innovation in clinical reasoning education, the Accreditation Council for Graduate Medical Education (ACGME) should revise its core competencies to include clinical reasoning. The core competencies have proven to be an effective means of expanding educational innovation across the United States and ensuring buy-in across a diverse array of institutions and disciplines. Reformulating the ACGME core competencies to include clinical reasoning would spark much-needed educational innovation and scholarship in graduate medical education, as well as collaboration across institutions in this vital aspect of physicianship, and ultimately, could contribute to a reduction of patient suffering by better preparing trainees to build individual, team-based, and system-based tools to monitor for and avoid diagnostic error.

The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners.

Background Excellence in clinical reasoning is one of the most important outcomes of medical education programs, but assessing learners' reasoning to inform corrective feedback is challenging and unstandardized. Methods The Society to Improve Diagnosis in Medicine formed a multi-specialty team of medical educators to develop the Assessment of Reasoning Tool (ART). This paper describes the tool development process. The tool was designed to facilitate clinical teachers' assessment of learners' oral presentation for competence in clinical reasoning and facilitate formative feedback. Reasoning frameworks (e.g. script theory), contemporary practice goals (e.g. high-value care [HVC]) and proposed error reduction strategies (e.g. metacognition) were used to guide the development of the tool. Results The ART is a behaviorally anchored, three-point scale assessing five domains of reasoning: (1) hypothesis-directed data gathering, (2) articulation of a problem representation, (3) formulation of a prioritized differential diagnosis, (4) diagnostic testing aligned with HVC principles and (5) metacognition. Instructional videos were created for faculty development for each domain, guided by principles of multimedia learning. Conclusions The ART is a theory-informed assessment tool that allows teachers to assess clinical reasoning and structure feedback conversations.